Appointment Form 3 – NOTICE OF PRIVACY PRACTICES Unique Lingerie, Inc. 202 SW 17th St. UNIT C Ocala FL 34471 Phone: 352.877.8700 eFax: 352-608-9718 Office Fax: 352-421-5592 Acknowledgement of Receipt ofNOTICE OF PRIVACY PRACTICESforUnique Lingerie, Inc. Acknowledgement for the Notice of Privacy Practices: I hereby certify that I have received a copy of the "Notice of Privacy Practices" which describes how Unique Lingerie, Inc. may disclose my protected health information. It will be used and disclosed in carrying out my treatment, collection of bills, or health care operations and for other purposes that are not permitted by law. It also describes my rights to access and control any of my written and oral health information. My "protected health information" means any of my written and oral health information, including demographic data that can be used to identify me. This is health information that is created or received by Unique Lingerie, Inc. and that relates to my past, present or future physical or mental health condition. Unique Lingerie, Inc. reserves the right to change the privacy practices that are described in its Notice of Privacy Practices. Unique Lingerie, Inc. also reserve the right to apply these changes retroactively to PHI received before the change in privacy practices. I understand that I may obtain a revised Notice of Privacy Practices by calling Unique Lingerie, Inc. and requesting a revised copy be sent in the mail or by asking for one at the time of my next appointment. Signature of Patient/Personal Representative(Full Name): Print Name of Patient/Personal Representative(Full Name): Email of Patient/Personal Representative: Date:
